Right ventricular assessment of the adolescent footballer's heart

INTRODUCTION

Athletic training can result in electrical and structural changes of the right ventricle that may mimic phenotypical features of arrhythmogenic right ventricular cardiomyopathy (ARVC), such as T-wave inversion and right heart dilatation. An erroneous interpretation may have consequences ranging from false reassurance in an athlete vulnerable to cardiac arrhythmias, to unnecessary sports restriction in a healthy individual. The primary aim of this study was to define normal RV dimension reference ranges for academy adolescent footballers of different ethnicities. Secondary aims include analysis of potential overlap between this adolescent group with ARVC criteria and comparison with normal adult ranges.

RESULTS

Electrocardiographic (ECG) and echocardiographic data of 1087 academy male footballers aged between 13 and 18 years old (mean age 16.0 ± 0.5 years), attending mandatory cardiac screening were analysed. Ethnicity was categorised as white (n = 826), black (African/Caribbean; n = 166) and mixed-race (one parent white and one parent black; n = 95). Arrhythmogenic right ventricular cardiomyopathy major criteria for T-wave inversion was seen in 3.3% of the cohort. This was more prevalent in black footballers (12%) when compared to mixed race footballers (6.3%) or white footballers (1%), P < 0.05. Up to 59% of the cohort exceeded adult reference ranges for some of the right ventricular parameters, although values were similar to those seen in adult footballers. There were no differences in right ventricular dimensions between ethnicities. In particular, the right ventricular outflow tract diameter would fulfil major criteria for ARVC dimension in 12% of footballers. Overall, 0.2% of the cohort would fulfil diagnosis for 'definite' arrhythmogenic right ventricular cardiomyopathy and 2.2% would fulfil diagnosis for 'borderline' arrhythmogenic right ventricular cardiomyopathy for RV dimensions and ECG changes. This was seen more frequently in black footballers (9.9%) than mixed race footballers (3.9%) or white footballer (0.6%), P < 0.05. Among athletes meeting definite or borderline arrhythmogenic right ventricular cardiomyopathy criteria, no cardiomyopathy was identified after comprehensive clinical assessment, including with cardiac magnetic resonance imaging, exercise testing, ambulatory electrocardiograms and familial evaluation.

CONCLUSION

Right heart sizes in excess of accepted adult ranges occurred in as many as one in two adolescent footballers. Structural adaptations in conjunction with anterior T-wave inversion may raise concern for ARVC, highlighting the need for evaluation in expert settings.

Review of standard paediatric neuroradiology MRI protocols from 12 UK tertiary paediatric hospitals: is there much variation between centres?

AIM

To investigate how magnetic resonance imaging (MRI) examinations are protocolled in tertiary paediatric neuroradiology centres around the UK for some of the more common presentations encountered in paediatric neuroradiology, and to identify any variations of note.

MATERIALS AND METHODS

All 19 UK tertiary paediatric neuroradiology centres registered with the British Society of Neuroradiologists-Paediatric Group were contacted and asked if they could provide a copy of their standard MRI protocols. Twelve responded (63%) and 10 of the more common presentations were selected and the standard acquired sequences obtained at each participating centre were compared. Where available the collated protocols were also compared against current published guidance.

RESULTS

The basic sequences carried out by centres around the UK are similar; however, there are lots of variations overall. The only standardised protocol currently being implemented nationally in paediatric imaging is that for brain tumours. Otherwise, chosen protocols are generally dependent on the preferences and technical capabilities of individual centres. Suggested published protocols also exist for non-accidental injury (NAI), multiple sclerosis, epilepsy, and head and neck imaging.

CONCLUSIONS

The differences in MRI protocolling depend in part on technical capabilities and in part on the experience and preferences of the paediatric neuroradiologists at each centre. For most presentations, there is no consensus as to what constitutes the perfect protocol. The present results will be useful for specialist centres who may wish to review their current protocols, and for more generalist centres to use as a reference to guide their MRI protocolling.

Automated identification system for ships data as a proxy for marine vessel related stressors

An increasing number of marine conservation initiatives rely on data from Automatic Identification System (AIS) to inform marine vessel traffic associated impact assessments and mitigation policy. However, a considerable proportion of vessel traffic is not captured by AIS in many regions of the world. Here we introduce two complementary techniques for collecting traffic data in the Canadian Salish Sea that rely on optical imagery. Vessel data pulled from imagery captured using a shore-based autonomous camera system ("Photobot") were used for temporal analyses, and data from imagery collected by the National Aerial Surveillance Program (NASP) were used for spatial analyses. The photobot imagery captured vessel passages through Boundary Pass every minute (Jan-Dec 2017), and NASP data collection occurred opportunistically across most of the Canadian Salish Sea (2017-2018). Based on photobot imagery data, we found that up to 72 % of total vessel passages through Boundary Pass were not broadcasting AIS, and in some vessel categories this proportion was much higher (i.e., 96 %). We fit negative binomial General Linearized Models to our photobot data and found a strong seasonal variation in non-AIS, and a weekend/weekday component that also varied by season (interaction term p < 0.0001). Non-AIS traffic was much higher during the summer (Apr-Sep) and during the weekend (Sat-Sun), reflecting patterns in recreational vessel traffic not obligated to broadcast AIS. Negative binomial General Additive Models based on the NASP data revealed strong spatial associations with distance from shore (up to 10 km) and non-AIS vessel traffic for both summer and winter seasons. There were also associations between non-AIS vessels and marina and anchorage densities, particularly during the winter, which again reflect seasonal recreational vessel traffic patterns. Overall, our GAMs explained 20-37 % of all vessel traffic during the summer and winter, and highlighted subregions where vessel traffic is under represented by AIS.

Automated left ventricular dimension assessment using artificial intelligence

Background and purpose

Artificial intelligence (AI) has the potential to greatly improve efficiency and reproducibility of quantification in echocardiography, but to gain widespread use it must both meet expert standards of excellence and have a transparent methodology. We developed an online platform to enable multiple collaborators to annotate medical images for training and validating neural networks.

Methods

Using our online collaborative platform 9 expert echocardiographers labelled 2056 images that comprised the training dataset. They labelled the four points from where the standard parasternal long axis (PLAX) measurements (interventricular septum, posterior wall, left ventricular dimension) would be made. Using these labelled images we trained a 2d convolutional neural network to replicate these labels. Separately, we curated an external validation dataset of the systolic and diastolic frames of 100 PLAX acquisitions. Each of these images were labelled twice by 13 different experts, and the average of the 26 measurements was taken as the consensus standard.

We then compared the individual experts and the AI measurements on the external validation dataset to the consensus standard, and calculated the precision standard deviation (SD) of the signed differences from the consensus standard.

Results

For diastolic septum thickness, the AI had a precision SD of 1.8 mm (ICC 0.81; 95% CI 0.73 to 0.97), compared with 2.0 mm for the individual experts (ICC 0.64; 95% CI 0.57 to 0.72). For diastolic posterior wall thickness, the AI had a precision SD 1.4 mm (ICC 0.54; 95% CI 0.38 to 0.66), and the individual experts 2.2 mm (ICC 0.37; 95% CI 0.29 to 0.46).

The AI's precision SD for left ventricular internal dimension was 3.5 mm (ICC 0.93, 95% CI 0.90 to 0.94), and for individual experts was 4.4mm (ICC 0.82, 95% CI 0.78 to 0.95). Both the experts and AI performed better in diastole than systole (precision SD AI 2.5mm vs 4.3mm, p&lt;0.0001; experts 3.3mm vs 5.3mm, p&lt;0.0001).

Conclusions

AI trained by a group of echocardiography experts was able to perform PLAX measurements which matched the reference standard more closely than any individual expert's own measurements.

This open, collaborative approach may be a model for the development of AI that is explainable to, and trusted by clinicians.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIHR Imperil BRC ITMATDr Howard was additionally funded by Wellcome. Online collaborative platformResults of AI and experts

Right ventricular assessment of the adolescent footballers heart: impact of ethnicity

Introduction

Athletic training often results in electrical and structural changes that may mimic phenotypical features of pathological cardiomyopathies. These physiological changes are influenced by age, ethnicity and sporting discipline. The presence of such changes that overlap with diseases implicated in exercise related sudden cardiac death may require comprehensive assessment to confirm or refute the presence of disease. One such potential physiological overlap with pathological change in athletes can occur in arrhythmogenic right ventricular dysplasia (ARVD), with features including chamber dilatation and T-wave inversion (TWI). An erroneous interpretation may have profound consequences ranging from false reassurance in a vulnerable athlete to unfair disqualification in a healthy individual. Therefore, it is important for the clinician to distinguish physiology from pathology.

Purpose

Studies detailing the physiological adaptation to exercise on the right ventricle (RV) of adolescent athletes are fewer compared to the left ventricle, with even fewer reports describing the impact of ethnicity on the RV. We set out to describe the normal dimensions of the RV of academy football players.

Results

ECG and echocardiographic data of 3000 academy male footballers were analysed, aged between 13 and 18 years old (mean age 16.4±0.5 years), who underwent mandatory cardiac screening. Ethnicity was categorised as white (n=1000), black (African/Caribbean; n=1000) and mixed-race (one parent white and one parent black; n=1000). ARVD major criteria for TWI was seen in 6.3% of the cohort. This was more prevalent in black footballers (3.7%) when compared to mixed race footballers (2%) or white footballers (0.6%), p&lt;0.05. In up to 67% of the overall cohort, RV values exceeded those for normal adult reference ranges. There were no differences in RV dimensions between ethnicities (Tables 1 & 2). If ARVD criteria was applied, 13.2% would fulfil major ARVD criteria for right ventricular outflow tract. This was also demonstrated for RVOT dimensions (6.1% - 23.6%; Figure 1). Overall, 0.2% of the cohort would fulfil diagnosis for “definite” ARVD and 2.2% would fulfil diagnosis for “borderline” ARVD. This was seen more frequently in black footballers (9.9%) than mixed race footballers (3.9%) or white footballer (0.6%), P=0.0005. Among athletes meeting definite or borderline ARVD criteria, no cardiomyopathy was identified after comprehensive clinical assessment.

Conclusion

This is the largest study to our knowledge that reports RV dimension data among adolescent footballers of different ethnicities. Right heart sizes in excess of standard adult ranges occurred in as many as one in 22 athletes. It is not unusual to observe values that would overlap with criteria for ARVD. As with LV parameters, variations in terms of ethnicity should be accounted for when considering RV dimensions and ECG changes when performing routine cardiac assessments of adolescent athletes.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): National Institute for Health Research

Psychometric Properties of the MDADI-A Preliminary Study of Whether Less is Truly More?

The MD Anderson Dysphagia Inventory (MDADI) is a 20-item dysphagia-specific QOL questionnaire with four subscales: global, emotional, functional, and physical. It is widely used in clinical practice and in research; however, its psychometric properties have been under-researched. We aim to evaluate the organisation of the MDADI subscales and identify any redundant items. The MDADI is a routinely collected outcome measure at two centres in northeast England. Questionnaires completed at three months following treatment were extracted from these existing databases. Factor analysis was carried out with the aim of reducing redundancy among the set of questionnaire items. Cases with missing values were excluded. A total of 196 complete patient questionnaires were used in factor analysis. A one-factor model accounted for around 50% of the total variance in item responses. The top five endorsed items (abbreviated by the questionnaire item keywords: Excluded, Irritate, Esteem, Social, and Why) in this one factor appeared in three (emotional, functional, and physical) of the four supposed MDADI subscales, i.e. global, emotional, functional, and physical. Our results suggest an overlap of three MDADI subscales across the top five endorsed items. The content of the top five questions all appear related to the psychosocial aspects of swallowing. This implies some redundancy of the items in the original subscales of the questionnaire. Using the most endorsed items, it appears feasible to abbreviate the 20-item MDADI questionnaire to a 5-item “MiniDADI” questionnaire, which is likely to have greater utility in routine clinical practice outside of research settings.

Toxicological analysis of aerosols derived from three electronic nicotine delivery systems using normal human bronchial epithelial cells

Electronic nicotine delivery systems (ENDS) are a rapidly growing global market advertised as a safer alternative to combustible cigarettes. However, comprehensive investigations of END aerosol physicochemical and toxicological properties have not been fully explored across brands to assess relative safety. In this study, we evaluated aerosols collected from three ENDS - Juul Fruit Medley (5% nicotine), Logic Power (2.4% nicotine), and Mistic (1.8% nicotine). ENDS aerosols were generated using standard machine puffing regimen and collected with a novel fluoropolymer condensation trap. Triple quadrupole-inductively coupled plasma-mass determined the presence of heavy metals in collected aerosols. The toxicological effects of ENDS aerosols on normal human bronchial epithelial cells (NHBE) were investigated using cellular viability, reactive oxygen species, oxidative stress assays, along with DNA damage assessments using the CometChip©. Results indicated the total metal concentrations within collected ENDS aerosols were higher for Mistic and Logic compared to Juul. Logic Power aerosols elicited higher reactive oxygen species levels than Mistic and Juul in NHBE after 24-h exposure. Similar dose-dependent reductions of cellular viability and total glutathione were found for each exposure. However, Logic and Juul aerosols caused greater single stranded DNA damage compared to Mistic. Our study indicates that regardless of brand, ENDS aerosols are toxic to upper airway epithelial cells and may pose a potential respiratory hazard to occasional and frequent users.

Characterization of an aerosol generation system to assess inhalation risks of aerosolized nano-enabled consumer products

Objective: The aerosolization of common nano-enabled consumer products such as cosmetics has significantly increased engineered nanoparticle inhalation risks. While several studies have investigated the impact of cosmetic dermal exposures, inhalation hazards of aerosolized cosmetics are much less known but could pose considerable harm to users due to potential co-exposure of nanoparticles and other product components.Materials and Methods: In this study, we developed a fully automated aerosol generation system to examine the aerosol properties of four aerosolized nano-enabled cosmetics using real-time monitoring and sampling instrumentation. Physicochemical characterization of aerosols was conducted using scanning electron microscopy coupled with energy dispersive x-ray spectroscopy (SEM-EDX). Characterization and calibration of animal exposure pods coupled to the system were also performed by measuring and comparing particle concentrations between pods.Results and Discussion: Results show peak emissions are shade dependent and varied between 12,000-22,000 particles/cm³ with modal diameters ranging from 36 nm-1.3 µm. SEM-EDX analysis determined that the original products and collected aerosols have similar morphological features consisting of micron-sized particles decorated with nanoparticles and crystalline structures. Mean total particle concentration in pods at 5 and 10 mg/m³ target levels were 2.22E + 05 #/cm³ and 4.33E + 05 #/cm³, respectively, with <10% variability between pods.Conclusions: The fully automated exposure platform described herein provides reproducible aerosol generation, conforms to recommended guidelines on chemical testing, and therefore is suitable for future in vivo toxicological assessments to examine potential respiratory hazards of aerosolized nano-enabled consumer products.

Determination of Immunoglobulin G in Bovine Colostrum and Milk Powders, and in Dietary Supplements of Bovine Origin by Protein G Affinity Liquid Chromatography: Collaborative Study

An AOAC collaborative study was conducted to evaluate an affinity LC procedure for measuring immunoglobulin G (IgG) in selected dairy powders. The powders were extracted with 0.15 M sodium chloride solution and the pH was adjusted to 4.6 to precipitate caseins, which would otherwise lead to an overestimation of IgG. The analyte was then bound to a commercially available Protein G affinity cartridge and selectively eluted with a glycine buffer at pH 2.5. Detection was at 280 nm and quantification was made against a calibration curve prepared from bovine serum IgG. The samples analyzed included the likely matrixes for which this assay will find commercial use, namely, high- and low-protein-content colostrum powders, tablets containing colostrum powder, and some IgG-containing dairy powders; milk protein isolate, whey protein concentrate, and skim milk powder. Eleven laboratories provided data for the study and assayed blind duplicates of six materials. The repeatability RSD values ranged from 2.1 to 4.2 and the reproducibility RSD values ranged from 6.4 to 18.5. The Protein G method with casein removal has adequate reproducibility for measuring IgG in colostrum-derived powders that are traded on the basis of IgG content as a colostral marker.

Randomised controlled trial of cognitive behavioural therapy in COPD

Anxiety is an important comorbidity in chronic obstructive pulmonary disease (COPD). We investigated if cognitive behavioural therapy (CBT), delivered by respiratory nurses, reduced symptoms of anxiety and was cost-effective. Patients with COPD and anxiety were randomised to CBT or self-help leaflets. Anxiety, depression and quality of life were measured at baseline, 3, 6 and 12 months. A cost-effectiveness analysis was conducted from a National Health Service hospital perspective and quality-adjusted life-years estimated using the EuroQol-5D questionnaire. In total, 279 patients were recruited. Group mean change from baseline to 3 months in the Hospital Anxiety and Depression Anxiety Subscale was 3.4 (95% CI 2.62-4.17, p<0.001) for the CBT group and 1.88 (95% CI 1.19-2.55, p<0.001) in the leaflet group. The CBT group was superior to leaflets at 3 months (mean difference in the Hospital Anxiety and Depression Anxiety Subscale was 1.52, 95% CI 0.49-2.54, p=0.003). Importantly, the CBT intervention was more cost-effective than leaflets at 12 months, significantly lowering hospital admissions and attendance at emergency departments. CBT delivered by respiratory nurses is a clinically and cost-effective treatment for anxiety in patients with COPD relative to self-help leaflets.

Impact of Alemtuzumab Scheduling on Graft-versus-Host Disease after Unrelated Donor Fludarabine and Melphalan Allografts

Alemtuzumab conditioning is highly effective at reducing the incidence of acute and chronic graft versus host disease (GVHD) in reduced intensity fludarabine and melphalan transplantation with ciclosporin monotherapy. Less frequent and lower dose scheduling may be used with sibling donors but an optimal regimen for matched unrelated donors has not been defined. In this retrospective observational study of 313 patients, the incidence and severity of GVHD was compared in patients receiving the standard 100mg regimen (20mg on day -7 to -3), 60mg (30mg day -4 and -2) or 50mg (10mg on day -7 to -3). Patients treated with 100mg, 60mg or 50mg developed acute GVHD grade I-IV with an incidence of 74%, 65% and 64%, respectively, while 36%, 32% and 41% developed chronic GHVD. An excess of severe acute grade III/IV GVHD was observed in the 50mg cohort (15% vs. 2-6%; p = 0.016). The relative risk of severe acute grade GVHD remained more than three-fold higher in the 50mg cohort, compared with 100mg, after adjustment for differences in age, gender mismatch, CMV risk and diagnosis (p = 0.030). The findings indicate that 60mg doses of alemtuzumab is comparable to 100mg but lower dosing may increase the risk of severe grade GVHD.

Does age of the sperm donor influence live birth outcome in assisted reproduction?

STUDY QUESTION

Does age of the sperm donor have an effect on reproductive outcomes (live birth rate and miscarriage occurrence) of donor insemination or in vitro fertilization treatment using donated sperm?

SUMMARY ANSWER

Live birth and miscarriage occurrence in assisted reproduction treatment using donor sperms was not found to be affected by the age of sperm donors up to 45 years old.

WHAT IS ALREADY KNOWN

Literature on the effect of sperm donor age on outcome of medically assisted reproduction is scarce. Most researchers agree that semen parameters deteriorate with increasing paternal age. However, there is no substantial evidence to suggest that this deterioration adversely affects the reproductive outcomes in couples undergoing medically assisted reproduction.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study analysed 46 078 first donor insemination treatments and fresh in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles using donated sperm from 1991 to 2012.

PARTICIPANTS/ DURATION/METHODS

The first fresh donor insemination and IVF/ICSI treatment cycles (46 078 treatment cycles) using donated sperm from the long-term anonymized data registry from 1991 to 2012 of the HFEA, the UK regulator, were analysed by the binary logistic modelling technique for association between sperm donor age and reproductive outcomes (live birth occurrence and miscarriage occurrence). The statistical package SPSS (version 21) was used for analysis and results were considered to be statistically significant if the P-value was <0.05.

MAIN RESULTS AND THE ROLE OF CHANCE

Of 46 078 women, 84.6% (N = 38 974) underwent donor insemination treatment and the remainder, 15.4% (N = 7104), had IVF/ICSI treatment with donor sperm. The live birth occurrence decreased with increasing female age in both treatment groups; In the donor insemination treatment group, it was 11.1% in 18-34 year old women, 8.3% in 35-37 year old women and 4.7% in 38-50 year old women. The corresponding figures in the IVF/ICSI treatment group were 28.9, 22.0 and 12.9% respectively. In each of these subgroups, no evidence of declining likelihood of live birth with increasing sperm donor age was found (P > 0.05). The miscarriage occurrence (i.e. number of miscarriages per 100 women commencing treatment) was 1.3% in 18-34 year old women, 1.9% in 35-37 year old women and 1.9% in 38-50 year old women undergoing donor insemination treatment. In the sperm donation IVF/ICSI treatment group, these figures were 5.7, 8.4 and 6.8% respectively. The results were not suggestive of any unfavourable effect of advancing sperm donor age on the odds of miscarriage occurrence (P > 0.05).

LIMITATIONS, REASONS FOR CAUTION

As sperm donors are a select population based on good semen indices, the generalization of results to the paternal population at large may not be possible. Although the study subgroups were controlled for female age, treatment modality and effect of previous treatment cycles, adjustments for certain potential compounding factors, such as smoking status, BMI of women and stimulation protocol used in IVF/ICSI treatment cycles, were not possible.

WIDER IMPLICATIONS OF THE FINDINGS

Live birth and miscarriage occurrence following assisted reproduction weren't adversely affected by increasing sperm donor age up to 45 years. In view of the increasing demand for donor sperm, further studies may be required to ascertain the safe upper age limit for sperm donors.

STUDY FUNDING/COMPETING INTERESTS

No funding was received from any individual or funding agency. NG was on a Commonwealth Scholarship for the duration of the study. The authors do not have any conflicts of interest to declare.

Predicting survival using clinical risk scores and non-HLA immunogenetics

Previous studies of non-histocompatibility leukocyte antigen (HLA) gene single-nucleotide polymorphisms (SNPs) on subgroups of patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT) revealed an association with transplant outcome. This study further evaluated the association of non-HLA polymorphisms with overall survival in a cohort of 762 HSCT patients using data on 26 polymorphisms in 16 non-HLA genes. When viewed in addition to an already established clinical risk score (EBMT-score), three polymorphisms: rs8177374 in the gene for MyD88-adapter-like (MAL; P=0.026), rs9340799 in the oestrogen receptor gene (ESR; P=0.003) and rs1800795 in interleukin-6 (IL-6; P=0.007) were found to be associated with reduced overall survival, whereas the haplo-genotype (ACC/ACC) in IL-10 was protective (P=0.02). The addition of these non-HLA polymorphisms in a Cox regression model alongside the EBMT-score improved discrimination between risk groups and increased the level of prediction compared with the EBMT-score alone (gain in prediction capability for EBMT-genetic-score 10.8%). Results also demonstrated how changes in clinical practice through time have altered the effects of non-HLA analysis. The study illustrates the significance of non-HLA genotyping prior to HSCT and the importance of further investigation into non-HLA gene polymorphisms in risk prediction.

A comparative study of reduced dose alemtuzumab in matched unrelated donor and related donor reduced intensity transplants

In vivo T cell depletion with 100 mg alemtuzumab prevents graft-versus-host disease (GVHD) in reduced intensity conditioned transplants but is associated with delayed immune reconstitution, a higher risk of infection and relapse. De-escalation studies have shown that a reduced dose of 30 mg is as effective as 100 mg in preventing GVHD in matched related donor (MRD) transplants. Dose reduction in matched unrelated donor (MUD) transplants is feasible but the comparative efficacy of alemtuzumab in this setting is not known and opinions vary widely concerning the optimal level of GVHD prophylaxis that should be achieved. Through retrospective analysis we made an objective comparison of MUD transplants receiving an empirically reduced dose of 60 mg, with MRD transplants receiving a 30 mg dose. We observed proportionate levels of alemtuzumab according to dose but an inverse relationship with body surface area particularly in MRD transplants. MUD transplants experienced more acute and chronic GVHD, higher T cell chimerism, more sustained use of ciclosporin and less need for donor lymphocyte infusion than MRD transplants. Thus, doubling the dose of alemtuzumab to 60 mg did not provide equivalent prevention of GVHD after MUD transplant although there was no difference in non-relapse mortality or survival compared with MRD transplants.

Determination of immunoglobulin G in bovine colostrum and milk powders, and in dietary supplements of bovine origin by protein G affinity liquid chromatography: collaborative study

An AOAC collaborative study was conducted to evaluate an affinity LC procedure for measuring immunoglobulin G (IgG) in selected dairy powders. The powders were extracted with 0.15 M sodium chloride solution and the pH was adjusted to 4.6 to precipitate caseins, which would otherwise lead to an overestimation of IgG. The analyte was then bound to a commercially available Protein G affinity cartridge and selectively eluted with a glycine buffer at pH 2.5. Detection was at 280 nm and quantification was made against a calibration curve prepared from bovine serum IgG. The samples analyzed included the likely matrixes for which this assay will find commercial use, namely, high- and low-protein-content colostrum powders, tablets containing colostrum powder, and some IgG-containing dairy powders; milk protein isolate, whey protein concentrate, and skim milk powder. Eleven laboratories provided data for the study and assayed blind duplicates of six materials. The repeatability RSD values ranged from 2.1 to 4.2% and the reproducibility RSD values ranged from 6.4 to 18.5%. The Protein G method with casein removal has adequate reproducibility for measuring IgG in colostrum-derived powders that are traded on the basis of IgG content as a colostral marker.

Quality of lamb meat from the Information Nucleus Flock

The effects of production and processing factors on tenderness, and colour of lamb meat produced from 7 locations as part of the Australian Sheep Industry CRC’s Information Nucleus flock were investigated, using data from 2052 lambs slaughtered in 2007. At 24 h post-slaughter, samples of m. longissimus lumborum (LL) and m. semimembranosus (SM) were collected for measurement of intramuscular fat (IMF), myoglobin, iron and copper and fresh meat colour (L*, a*, b*) and pH at 24 h measured on the LL. pH and temperature measurements made pre-rigor were used to calculate the pH at 18°C. Tenderness was measured by LL shear force at days 1 (SF1) and 5 (SF5) post-slaughter, the shear force difference (SF-diff) and SM compression and collagen concentration were determined. Retail colour stability was assessed using over-wrapped LL under simulated retail display for 3 days, according to the change in the oxymyoglobin/metmyoglobin ratio. All traits were affected by flock and date of slaughter (P < 0.001). After 4 days of ageing, 70–95% of the LL samples from all flocks, except for one, had acceptable tenderness for consumers based on their shear force. Low IMF, high LL pH at 18°C and high pH at 24 h increased SF1 and SF5 and also had an effect on SF-diff (P < 0.001). The retail colour of 44.8% of the samples on day 3 of retail display were lower than acceptable. Retail colour was influenced by IMF, pH18 and the concentration of iron and copper (P < 0.001). In conclusion, breeding and management practices that increase muscle IMF levels and reduce ultimate pH values and processing practices that result in moderate rates of pH fall post-slaughter, improve the tenderness of lamb. Extension of retail colour stability may be antagonistic to traits associated with tenderness and nutritional traits, particularly IMF and mineral levels.

Increase in tuberculin skin test converters among health care workers after a change from Tubersol to Aplisol

BACKGROUND

Comparability of the 2 commercially available tuberculin skin testing (TST) preparations, Aplisol (Parkdale Pharmaceuticals, Inc, Rochester, MI) and Tubersol (Aventis Pasteur, Inc, Swiftwater, PA), remains uncertain, particularly in groups that undergo repeated testing, such as health care workers.

METHODS

Data from the annual tuberculosis screening program for health care workers at the Kennedy Krieger Institute in Baltimore, Maryland, were analyzed. Conversion rates during 1997-2003 in workers screened with Tubersol (n = 8897 screenings) were compared with 1203 workers who underwent screening with Aplisol in 2004. Repeat testing with Tubersol was examined in those who converted in 2004 with Aplisol.

RESULTS

Annual TST conversion rates ranged from 0.3% to 0.9% between 1997 and 2003 using Tubersol. After switching to Aplisol in 2004, the TST conversion rate significantly increased to 2% (P < .001). Among 24 health care workers who were converters with Aplisol in 2004, only 6 of 23 (26%) were converters on repeat testing with Tubersol (1 declined retesting). None of the apparent converters (n = 24) had radiographic evidence of Mycobacterium tuberculosis infection, and there was no epidemiologic evidence of transmission. Reclassification based on Tubersol testing in 2004 resulted in conversion rates comparable with previous years.

CONCLUSION

We conclude that the change from Tubersol to Aplisol resulted in falsely elevated conversion rates. Our results support the guidelines from the Centers for Disease Control and Prevention recommendations that 1 product should be used consistently in populations undergoing periodic testing.

Echis time, under-carboxylated prothrombin and vitamin K status in intensive care patients

Vitamin K deficiency is a known cause of coagulopathy in hospitalized patients, but the extent of the problem has not been well assessed. This noninterventional, prospective observational study of 35 adults was undertaken in the intensive care unit (ICU) and examined the incidence of and the methods for diagnosing vitamin K deficiency. Measurements of prothrombin time, Echis time and plasma concentrations of under-carboxylated prothrombin (proteins induced in vitamin K absence or antagonism, PIVKA-II), vitamin K1 and ferritin were made during the 48 h after admission to the unit and repeated if coagulopathy developed later. Plasma vitamin K1 was low in 15 admissions (43%), in 11 cases of patients with coagulopathy and in four cases without coagulopathy. PIVKA-II was present in 12 cases (34%), of whom four had low vitamin K1 levels. All of the eight patients with raised PIVKA-II but normal vitamin K concentration were hyperferritinaemic. We conclude that low plasma vitamin K levels, suggestive of low tissue stores, are common in intensive care patients with or without coagulopathy. As 34% of patients had a raised PIVKA-II, this suggests that vitamin K stores may be insufficient to maintain full gamma-carboxylation of prothrombin and emphasize the need to anticipate vitamin K deficiency in the ICU setting by appropriate supplementation.

Ambulatory diagnoses-cluster statistics of patient visits at a clinic in the Amazon Region of Ecuador

INTRODUCTION

Mondana Clinic is a small rural clinic located in the Napo river region of the Amazon basin in Ecuador. Since its opening in 1997 the clinic has grown to be the primary health care facility for approximately 3000 individuals.

METHODS

A retrospective study was performed tabulating the ambulatory diagnosis, age, sex, and domicile of patients over a 9 month period in 1999.

RESULTS

During the study period there were 765 patient visits that resulted in at least one diagnosis. Of the patient visits, 175 (22.8%) resulted in multiple diagnoses. Women accounted for 58% of the patient visits, which is similar to the 60% of ambulatory patient visits made in the USA by women. The age distribution showed 66% of patients were under 25 years of age. When comparing diagnoses of males with females, several differences were noted. As expected, urinary tract infections were approximately four-fold more common in females than in males. Gastritis and headaches were also more common reasons for patient visits in the female population than in the male. Conversely, lacerations, abrasions, and contusions ranked higher in the male than in the female population for patient visits.

CONCLUSION

This study is the first to provide public health information for this region that will prove useful to the health professionals and funding agencies working in the region. Furthermore, it provides a baseline for comparison with other regions in Ecuador and South America in general, as well as comparisons with data-rich countries such as the USA.

Improving the positive predictive value of screening for developmental language disorder

In a previous study, we reported the results of an early language screening program in which 306 children were screened using a parent-report questionnaire sent through the mail (Klee et al., 1998). A sample of the children screened were given clinical evaluations within a month of screening (n = 64) and again 1 year later (n = 36). Although the screening program correctly identified 91% of 2-year-olds with language delay, it produced a large number of over-referrals. In the present study we examine a revised screening criterion designed to reduce the number of false positives. The revised criterion generated fewer positive screens overall than the original and resulted in improved specificity (96% vs. 87%) and positive predictive value (77% vs. 51%), while maintaining the high sensitivity (91%) and negative predictive value (98%) of the original criterion. We also propose a screening score based on the new criterion, designed to inform the process of deciding which children to bring in for further evaluation.

One nurse's experience with technology

This article examines the positive and negative aspects of working with a documentation and information management system from the unique perspective of a practicing home care nurse who was also a student. Aspects of the nightingale tracker technology that are comparable with others used in home care, experiences of field testing, and the nurse's observations can help home care nurses see how this technology can benefit their practice.

The quality of life of older adults with urinary incontinence: determining generic and condition-specific predictors

Urinary incontinence (UI) is an unpleasant problem for many adults. This study determined the importance of demographic, health and incontinence variables for the generic and incontinence-specific quality of life (QoL) of older adults (age > or = 60 years). Telephone surveys of adults reporting at least weekly episodes of UI (n = 435) were conducted as part of a randomized, controlled trial. Logistic regression analyses showed that the predictors of generic and incontinence-specific QoL differed. Life satisfaction, a generic outcome, was predicted by education, the number of days in bed due to health problems, the number of days not feeling well and the amount of urine lost. Generic health was related to education, the number of days sick in the previous 30 days and the number of days health issues restricted activities. The incontinence-specific QoL outcomes were predicted by age, mobility difficulties, the amount of urine lost, the frequency of UI, and the number of daytime and night-time voids. The specific QoL measures provide a different profile of those most affected in this sample than that obtained by the generic measures. The most affected are younger persons with severe urine loss. Older persons may have other conditions impinging on QoL and may have adapted behaviourally and psychologically to urine loss.

Gamma delta T lymphocytes regulate the induction and maintenance of oral tolerance

Oral administration of Ag, over a period of several days, induces a state of tolerance that is associated with activation of CD8+ T cells that can transfer unresponsiveness to naive syngeneic hosts. We previously demonstrated that these T cells are not CTL precursors and that they inhibit responses by CD8+ CTL, as well as Ab and CD4+ T cell responses. Activation of noncytolytic, CD8+ suppressor T cells by oral Ag is a process that is not understood. In these studies, we asked whether depletion of the gamma delta T cells altered induction of oral tolerance. Injection of the anti-delta-chain Ab (GL3) down-modulated the expression of gamma delta TCR and inhibited the induction of oral tolerance to OVA, as measured by Ab, CD4+, and CD8+ T cell responses. GL3 did not activate IL-2 secretion that could be detected in the serum, nor did it induce IL-2R expression by intraepithelial lymphocytes, suggesting that GL3 inhibited the function of gamma delta T cells rather than activating them. This interpretation is supported by our observation that oral administration of Ag did not induce tolerance in TCR-delta knockout mice. These data suggest that gamma delta T cells play a critical, active role in tolerance induced by orally administered Ag.

Gamma delta T lymphocytes regulate the induction and maintenance of oral tolerance

Oral administration of Ag, over a period of several days, induces a state of tolerance that is associated with activation of CD8+ T cells that can transfer unresponsiveness to naive syngeneic hosts. We previously demonstrated that these T cells are not CTL precursors and that they inhibit responses by CD8+ CTL, as well as Ab and CD4+ T cell responses. Activation of noncytolytic, CD8+ suppressor T cells by oral Ag is a process that is not understood. In these studies, we asked whether depletion of the gamma delta T cells altered induction of oral tolerance. Injection of the anti-delta-chain Ab (GL3) down-modulated the expression of gamma delta TCR and inhibited the induction of oral tolerance to OVA, as measured by Ab, CD4+, and CD8+ T cell responses. GL3 did not activate IL-2 secretion that could be detected in the serum, nor did it induce IL-2R expression by intraepithelial lymphocytes, suggesting that GL3 inhibited the function of gamma delta T cells rather than activating them. This interpretation is supported by our observation that oral administration of Ag did not induce tolerance in TCR-delta knockout mice. These data suggest that gamma delta T cells play a critical, active role in tolerance induced by orally administered Ag.

Chemistry of muconaldehydes of possible relevance to the toxicology of benzene

(Z,Z)-Muconaldehyde reacted with primary amines to give N-substituted-2(2'-oxoethyl)-pyrroles, which were reduced to N-substituted-2-(2'-hydroxyethyl)-pyrroles by sodium borohydride. The pyrrole-forming reaction is exhibited by valine and its methyl ester, and is being developed with terminal valine in hemoglobin as a means of dose monitoring (Z,Z)-muconaldehyde, a putative metabolite of benzene. Reactions in aqueous solution between (Z,Z)-muconaldehyde and adenosine, deoxyadenosine, guanosine, or deoxyguanosine leading to pyrrole-containing adducts are described. The elucidation of the structures of the adducts was assisted by the study of reactions between (Z,Z)-muconaldehyde and both nucleoside derivatives and a model compound for guanosine. Reactions of (Z,Z)-muconaldehyde are complicated by its isomerization to (E,Z)- and (E-E)-muconaldehyde. The kinetics of this process have been studied in benzene, acetonitrile, and dimethylsulfoxide.

Sleep history is neglected diagnostic information. Challenges for primary care physicians

Sleep problems are treatable causes of morbidity and mortality, but little is known about how often the history fundamental to diagnosis is obtained. We recorded the frequency of sleep histories during encounters with simulated patients by 20 experienced primary care practitioners, 23 uninstructed medical interns, and 22 interns who had previous instruction about sleep disorders. Sleep histories were uncommonly obtained by uninstructed physicians (0% of practitioners, 13% of interns), but trained interns more often (81.8%) asked about sleep. If sleep problems are to be prioritized, major changes in physician education and behaviors are essential. Focused instruction about sleep influences physician behavior.

Association between indoor residential contamination with methyl parathion and urinary para-nitrophenol

Methyl parathion, a pesticide listed by the U.S. Environmental Protection Agency in Toxicity Category I (i.e., most toxic), is not licensed for indoor use, and human exposure has resulted in the deaths of infants and children. From January 1991 through November 1994, an unlicensed pesticide applicator sprayed the interior of more than 200 homes in Lorain County, Ohio, with methyl parathion. To measure the environmental contamination this spraying caused, we measured methyl parathion in residential samples (air filtration and surface wipe) collected from a subset of 64 homes. To measure human exposure, we collected urine samples from 142 people living in these homes and measured urinary levels of para-nitrophenol, a methyl parathion metabolite. We then used a generalized estimating equation to evaluate the association between residential contamination and human exposure. The model included the age of the resident, the number of days between pesticide application and sample collection, and air and surface-wipe methyl parathion concentrations. As expected, the air and surface-wipe concentrations each had a significant inverse relationship with the number of days between application and sample collection. The model explained 65.7% of the variation in urinary para-nitrophenol concentrations. The form of this model could be used to estimate urine p-nitrophenol in residents exposed to methyl parathion in situations where urine specimens are not available. We recommend site-specific validation of this model.

Is the stroke belt disappearing? An analysis of racial, temporal, and age effects

BACKGROUND AND PURPOSE

The stroke risk among white residents of the coastal plain of North Carolina, South Carolina, and Georgia (the "Stroke Belt") has been reported to be between 1.3 and 2.0 times the national average. In this study we examined (1) whether a similar excess risk exists for blacks in this region, (2) whether this regional excess stroke risk has decreased over time, and (3) whether the regional excess risk is consistent across ages from 45 to more than 85 years.

METHODS

Using data from the Compressed Mortality File, we estimated the annual relative stroke mortality risk for black and white men and women in a region of 153 coastal plain counties and compared these rates to those for the remainder of the United States.

RESULTS

The relative geographic excess risk of stroke death was similar for black residents and white residents of the Stroke Belt for both men and women. Despite the decline in stroke mortality, the relative increased risk of stroke death in the region has remained constant from 1968 to 1991; however, the pattern of excess risk across age differed significantly between race/sex groups.

CONCLUSIONS

These data show that the Stroke Belt continues to exist for blacks and whites and for men and women. Although the specific causes of the Stroke Belt remain unknown, the public health impact is staggering, with a greater than 40% excess risk of stroke mortality and more than 1200 excess stroke deaths annually.

The mobilization of ferritin iron by liver cytosol. A comparison of xanthine and NADH as reducing substrates

Considerable evidence suggests that the release of iron from ferritin is a reductive process. A role in this process has been proposed for two hepatic enzymes, namely xanthine oxidoreductase and an NADH oxidoreductase. The abilities of xanthine and NADH to serve as a source of reducing power for the enzyme-mediated release of ferritin iron (ferrireductase activity) were compared with turkey liver and rat liver homogenates. The maximal velocity (Vmax.) for the reaction with NADH was 50 times greater than with xanthine; however, the substrate concentration required to achieve half-maximal velocity (Km) was 1000 times less with xanthine than with NADH. NADPH could be substituted for NADH with little loss in activity. Dicoumarol did not inhibit the reaction with NADH or NADPH, demonstrating that the ferrireductase activity with those substrates was not the result of the liver enzyme 'DT-diaphorase' [NAD(P)H dehydrogenase (quinone)]. A flavin nucleotide was required for ferrireductase activity with rat and turkey liver cytosol when xanthine, NADH or NADPH was used as the reducing substrate. FMN yielded twice the activity with NADH or NADPH, whereas FAD was twice as effective with xanthine as substrate. Kinetic comparisons, differences in lability and partial chromatographic resolution of the ferrireductase activities with the two types of reducing substrates strongly indicate that the ferrireductase activities with xanthine and NADH are catalysed by separate enzyme systems contained in liver cytosol. Complete inhibition by allopurinol of the ferrireductase activity endogenous to undialysed liver cytosol preparations and the ability of xanthine to restore equivalent activity to dialysed preparations indicate that the source of reducing power for the endogenous activity is xanthine. These studies suggest that xanthine, NADH or NADPH can serve as a source of reducing power for the enzyme-mediated reduction of ferritin iron, with a flavin nucleotide serving as the shuttle of electrons from the enzymes to the ferritin iron.